ASPIRIN EXACERBATED RESPIRATORY DISEASE (AERD) AND ASPIRIN DESENSITIZATION
Click link below to listen to NPR story “Aspirin Both Triggers and Treats an Often- Missed Disease”
AERD stands for Aspirin Exacerbated Respiratory Disease or also called Samter’s Triad. It is estimated that 10% of adults with asthma and 40% of patients with both asthma and nasal polyps have AERD. This is an adult condition with three cardinal features:
Respiratory reactions to aspirin and other non-steroidal anti-inflammatory drugs
Many patients with AERD are difficult to treat with respect to their sinus disease and asthma, often requiring nasal surgery every 1-3 years to treat rapid re-growth of nasal polyps, along with suffering multiple asthma exacerbations per year. The polyps can cause severe nasal obstruction, loss of sense of smell, and uncontrolled asthma.
What are the symptoms?
Patients with AERD/Samter’s Triad usually have asthma, nasal congestion, and nasal polyps, and often do not respond to conventional treatments. Many have experienced chronic sinus infections and can lose their sense of smell.
These reactions can include:
Increased nasal congestion or stuffiness
Eye watering or redness
Cough, wheezing, or chest tightness
Frontal headache or sensation of sinus pain
Flushing and/or a rash
Nausea and/or abdominal cramping
General feeling of malaise, sometimes accompanied by dizziness
What causes AERD?
The cause of AERD/ Samter’s Triad is not well understood, however patients with AERD have seemingly acquired overproduction of and sensitivity to chemicals known as leukotrienes and often have high levels of cells called eosinophils in their blood and in their sinuses, which may lead to chronic inflammation of the airways and sinuses. Leukotriene levels are further elevated after ingestion of aspirin or NSAIDS, which is why patients develop reactions to these medications, and why anti-leukotriene agents are used in the treatment of this condition.
What treatments exist for AERD?
Without aspirin desensitization, the typical treatment is multiple sinus surgeries, avoidance of aspirin and other NSAIDs,oral and intranasal steroids, anti-leukotriene medications, and treatment of asthma. Even with optimal therapy, the disease is often not well controlled with rapidly recurring polyps and frequent asthma flares. Alternatively, aspirin desensitization and therapy combined with surgery is a well-recognized therapeutic option for patients with AERD, particularly those with severe asthma and polyp disease.
What is aspirin desensitization?
In people with AERD/Samter’s Triad, aspirin desensitization is performed by administering gradually increasing doses of aspirin to minimize risk of a serious reaction in a hospital or clinic that specializes in such treatment. The dose is slowly increased until the patient is able to take a full dose (325 mg) of aspirin and is then considered desensitized and can continue to take aspirin and other NSAIDs safely.
The goal of an aspirin desensitization procedure is to have the patient begin long-term daily aspirin therapy, which can treat the underlying cause of AERD/Samter’s Triad and decrease the need for oral corticosteroid medications and reduce the frequency of sinus surgeries needed. Clinical studies have shown that aspirin desensitization followed by daily aspirin use reduces symptoms of asthma, nasal polyps and sinusitis. Approximately 87% of patients experienced improvements in their symptoms and were able to reduce their use of steroids and/or other medications.
Am I a candidate for aspirin desensitization?
Candidates for aspirin desensitization and treatment must fall into one of three categories:
Aspirin sensitive patients with asthma who are experiencing uncontrolled respiratory inflammation despite optimal medical management.
Aspirin sensitive patients requiring repeated sinus surgeries.
Aspirin sensitive patients who need aspirin or NSAIDs for the treatment of other diseases.
Who is not a candidate for aspirin desensitization?
Aspirin desensitization is not indicated for patients:
Who have had aspirin induced hives or anaphylaxis that do not require daily aspirin therapy for treatment of other conditions.
Who are pregnant.
What are the potential benefits associated with aspirin desensitization and treatment?
The most effective known treatment for AERD is aspirin therapy. The majority of patients with AERD who underwent aspirin desensitization experience the following benefits:
Improvement in asthma symptoms and fewer asthma attacks
Less requirement for medication to treat respiratory symptoms
Improvement in sense of smell and taste
Delayed regrowth of nasal polyps and fewer polyp surgeries
What are the risks associated with the aspirin desensitization procedure?
Since the doses given are usually much smaller that what you have taken in almost all cases, the reactions are no greater and usually less severe than the reaction you may have experienced previously when taking a full therapeutic dose. The most serious risk during the desensitization procedure is the development of a life-threatening asthma exacerbation. Other symptoms may include nasal congestion, profuse runny nose, tightness of the throat, flushing of the skin, hives, and rarely, a drop in blood pressure.
We will closely monitor your physical status, vital signs, oxygen saturation and lung function for 30 minutes up to three hours after each dose. If a reaction occurs, the procedure will be stopped and the symptoms will be treated with one or more inhalation treatments, nasal sprays, oral medications, and/or injections of medications to relieve the symptoms. The desensitization will then resume once the symptoms resolve.
What should I expect during the aspirin desensitization?
The desensitization process is generally performed in our office over the course of 2 days, though for some patients with severe asthma or a history of every severe reactions, admission to the hospital for the desensitization may be preferred. You will initially be given a very low dose of aspirin, and gradually higher doses of aspirin are given while you are closely monitored. The symptoms and severity of reactions vary from person to person, and therefore the exact protocol for each desensitization procedure is determined individually for each patient.
During the reaction your symptoms are likely to include one or more of the following:
Increased nasal congestion or stuffiness
Eye tearing, watering, itchiness or redness
Frontal headache or sensation of sinus pain
Headache or facial pain/pressure
Cough, wheezing, or “tightness” in the chest
Less commonly, you may experience:
Hives or a rash, Flushing of the face and upper body
Nausea and abdominal cramping or abdominal pain
Generalized feeling of being unwell
Throughout the desensitization procedure the nurses and doctors will monitor your progress and evaluate your lung function. Following a reaction and after you have been treated with any medications needed to stabilize your condition, further doses of aspirin will be given, starting with repeating the dose that you reacted to. Generally there is no additional reaction to the same dose when it is repeated. The desensitization is complete once you have received 325mg of aspirin (one “adult” aspirin tablet) without further reaction. After desensitization, you will be go home on a regimen of 325mg or 650mg of aspirin twice a day, depending on your individual case.
What are the risks associated with long-term aspirin treatment?
Long-term risks from aspirin include pain or bleeding of the stomach or stomach ulcers. Aspirin slows down blood clotting, so you may bleed longer if you cut yourself or have surgery. Once you are desensitized to aspirin, the risks of daily aspirin are small. If you take it with food, stomach problems are less likely. Taking an antacid can lessen stomach pain. Coated aspirin tablets that bypass the stomach before they dissolve are also recommended. There are additional medications that could be prescribed if needed. If you start bleeding anywhere in your body, stop taking aspirin and call your primary care physician and Allergy- Immunology specialist immediately.
You should not undergo an aspirin desensitization procedure if you are pregnant, and if you become pregnant, you should immediately stop taking aspirin.
What do I need to do prior to aspirin desensitization?
You will need to be evaluated by your Allergy- Immunology specialist to make sure your asthma is stable prior to the desensitization procedure and to start medications which may minimize your reactions. You may also need to have sinus surgery prior to undergoing aspirin desensitization.
Aspirin desensitization must be conducted in a medical setting equipped to handle life-threatening asthma attacks. Although the desensitization may be completed in two days, it may take longer. To ensure the utmost safety, you must not be ill and your asthma must be well controlled.
For the one week prior to desensitization, your asthma must be stable on all of your usual asthma controller medications. These medications should be continued during the procedure.You should also continue all other medications recommended by your Allergy specialist.
How long is the Aspirin Desensitization procedure?
The aspirin desensitization usually takes 8-9 hours over two days. Expect to arrive early as directed by the medical staff. Since you are here for the whole day please bring books, laptop, snacks and / or other activities.
What do I do after desensitization?
You need to continue your daily dose of aspirin. Enteric coated aspirin helps lessen the effects of stomach irritation. In time, you will slowly notice improvement of your asthma and nasal symptoms. Typically the doctor will see you back one month after completing the aspirin desensitization.
Once desensitized to aspirin, you are most likely desensitized to other NSAIDs. Thus, if you are desensitized to aspirin and are taking it regularly you can take other NSAID medications, but do not exceed the recommended dose and check with your doctors to make sure they are safe to take in addition to your daily aspirin dose.
What treatment will I be on following aspirin desensitization?
Once desensitized and on long-term aspirin treatment, desensitization is maintained only as long as you continue to take uninterrupted aspirin doses. Aspirin should not be discontinued without speaking to your Allergy- Immunology specialist. If you need to hold aspirin for a surgical procedure, please call our office for the protocol to hold aspirin prior to elective surgery.
What if I miss a dose, am I still desensitized?
Once desensitized, your body can tolerate one or two days without aspirin. If you forget to take your aspirin and remember within 48 hours since your most recent dose, simply take your usual dose. After 48 hours of a missed dose, your body begins to lose the desensitized state. You should not consider yourself desensitized after missing a dose for 48 hours or more. If you take aspirin then, you could have a reaction. Call your doctor for instructions if a dose is missed for 48 hours or more. If you miss more than 3-5 days of aspirin doses, you may need to undergo another full desensitization procedure.